Relief of pain symptoms in children after tonsillotomy

Indications for complete removal of the tonsils (tonsillectomy):

Frequent exacerbations of chronic tonsillitis
Chronic tonsillitis with complications (rheumatism, infectious nonspecific polyarthritis, diseases of the heart, kidneys, thyroid gland, some diseases of the nervous system, skin, etc.).
Purulent complications (peritonsillar abscess, phlegmon of the neck);
Ineffectiveness of conservative treatment of uncomplicated chronic tonsillitis, carried out in a complex of 2-3 courses.
Obstructive sleep apnea syndrome (snoring accompanied by pauses in breathing during sleep) with enlarged palatine tonsils;
Neoplasms of the palatine tonsil.

Laser tonsil removal

In medicine, carbon dioxide or diode lasers are used. The cells of the body contain from 60 to 90% fluid. When a laser is applied to an area of tissue, its temperature rises and the liquid begins to evaporate and the protein molecules dry out.

Since the laser energy is mainly distributed at a depth of 2-3 mm, the result is a sequential stratification effect with simultaneous cauterization (coagulation) of small blood vessels. Therefore, the laser cut is almost bloodless. This effect is important - blood loss during surgery is significantly reduced, and the surgeon, working on a dry surface, has a larger field of view.

Advantages of the laser tonsil removal method

When removing tonsils, the destructive and coagulating effects of a laser beam are involved. The first allows the tissue to be removed, the second clots the blood at the incision site and seals the vessels, which prevents bleeding and infection of the wound.

Radio wave method for tonsil removal

The radio signal transmitted by the electrode causes the evaporation of intracellular fluid and, as a result, tissue dissection. High-frequency waves are absorbed by intracellular fluid, thereby reducing the risk of damage to adjacent organs and tissues.

In the photo, an operation to remove tonsils is performed by Dr. Andrey Borisovich Starosvetsky, otolaryngologist, rhinosurgeon, candidate of medical sciences.

The operation is performed using the radio wave method under local anesthesia.

Advantages of the radio wave tonsil removal method

Minimal tissue damage during incision:
minimal necrosis in the area of the surgical wound and adjacent tissues;
Acceleration of tissue regeneration processes:
low postoperative wound pain.
Sterilizing effect:
High cosmetic effect:

Comparative characteristics of the two methods

Laser tonsil removal

Carbon dioxide laser is used (CO2 laser)

the operation is almost bloodless
lower risk of bleeding after surgery
faster wound healing compared to traditional removal
less pain in the postoperative period
Minuses:
heating of surrounding tissues, there may be burns to the edges of the wound.

Radio wave tonsil removal

Surgitron radiosurgical device is used

the operation is also almost bloodless
radio wave produces an antibacterial effect, reducing the likelihood of inflammation after surgery
postoperative swelling in the wound is less pronounced, the wound heals much faster
there are no burns or damage to healthy tissues, because the effect of the cut is carried out without physical pressure, the removal of the tonsil is carried out carefully
early complete tissue healing without the formation of a rough scar

In some cases, to achieve maximum effectiveness, doctors can use a combined method: both laser and radio wave.

After discharge

The duration of postoperative rehabilitation averages from 6 to 12 weeks and depends on the type of surgery. The approximate recovery time will be explained to you by your attending physician. Upon returning home, you may experience discomfort and general weakness - this is a normal rehabilitation process.

Activity

After surgery, we recommend that you be as active as possible in your health. Try to walk every day. Just walking down the street or walking on a gym will do. If the weather is not very suitable for walking, you can spend time in the shopping center. Climbing stairs is also suitable as a workout. Do not lift more than 3-5 kg for 4-6 weeks after surgery. Before returning to work, discuss this with your operating surgeon at your first postoperative visit. We do not recommend that you drive a car until the pain is eliminated.

Pain

Moderate chest pain is common after thoracic surgery. The intensity and duration of pain is individual for each patient, but usually goes away within the first month. In addition to pain, you may experience numbness in the suture area and below, tingling and/or increased sensitivity of the skin in this area. These sensations are normal and will also subside in the postoperative period. If pain or other sensations begin to intensify for several days in a row, this is a reason to contact your doctor.

Medicines

Mostly you will be prescribed painkillers. We prefer non-steroidal anti-inflammatory drugs: ketanov, ibuprofen (Nurofen-express), Nise (imisulide), xefocam (lornaxicam), diclofenac. Other painkillers will also work. It should be remembered that these medications irritate the stomach and should be taken after meals. Food should not be too spicy or irritating. If you take painkillers for more than 5-7 days, you should start taking medications that protect the stomach (omeprazole 20-40 mg at night).

You need to watch your diet, drink more fluids, eat more fruits and other foods containing fiber. The intestines should be emptied at least once every 2-3 days. If you are prone to constipation, you can take magnesia or Duphalac.

Postoperative wound care

The surgical incision area should be kept dry and clean. Do not use creams or ointments. You should shower once a day. You can wash with soap or shower gel and do not rub the seam area with a washcloth. After a shower, the postoperative wound should be carefully dried and treated with a solution of brilliant green or potassium permanganate. There is no need to apply any bandages. After all the crusts fall off from the wound on their own and a pink, smooth scar appears, treatment can be stopped. Avoid taking baths for the first 3-4 weeks.

Preoperative preparation

Directly for the operation, it is necessary to undergo a preoperative examination, the scope of which is determined by the doctor after the examination.

Preoperative preparation is standard:

Laboratory tests - general blood test, blood biochemistry, blood for RW, HIV, hepatitis B and C, coagulogram, Rh factor, blood group.
Instrumental data - ECG, fluorography or chest x-ray.
Conclusion of specialists - therapist (pediatrician) and dentist about the absence of contraindications to surgical intervention.

Symptoms of inflammation in the mouth

Inflammation of the oral mucosa involves not only its superficial layers, but also often the gums and periodontium. The latter is the ligamentous apparatus of the tooth and holds it in the bone. When these structures are damaged, the following complaints and symptoms arise: pain and redness, bleeding, swelling, the appearance of periodontal pockets, and an unpleasant odor. As the process progresses, suppuration and mobility of supporting teeth and enlargement of regional lymph nodes may appear. All of the above symptoms require specialist intervention, elimination of the cause and treatment.

Anesthesia

Tonsillectomy surgery is performed under both local anesthesia and general anesthesia (anesthesia). Both methods of pain relief have pros and cons, so the decision is made by the attending doctor, taking into account the health condition and wishes of the patient.

Local anesthesia

The classic surgical technique (under local anesthesia) has been performed for many decades and still exists today. An anesthetic solution in an amount of about 20 ml is injected into several points around the tonsil - usually 1% lidocaine with the addition of adrenaline (to reduce bleeding). The effect is that the tissues are deeply impregnated with the drug, so the pain is almost not felt, and the tonsil appears to be raised above the palatine arches and is easy to isolate. This technique is called infiltration anesthesia.

If the patient has had allergic reactions to these drugs, they are replaced with ultracaine. Next, the operating doctor proceeds directly to removing the tonsils. The patient is only required to strictly follow his instructions. A tonsillectomy lasts about half an hour; before sending the patient into the room, the surgeon carefully checks whether the bleeding has stopped. This is an important point in the operation.

General anesthesia (anesthesia)

Nowadays, tonsillectomy is performed more and more often under general anesthesia. This is due to the fact that anesthetic equipment and drugs for anesthesia have changed a lot recently. Modern anesthetics are considered to be of a high safety class; they are non-toxic and do not carry the same complications as before. Anesthesia is easily tolerated by the patient and feels similar to normal sleep.

The photo shows an anesthesia device from the German company Drager used in the clinic.

To carry out general anesthesia, the patient is carefully examined; before the operation, he is examined by an anesthesiologist, since, despite the safety of anesthesia, if there are deviations in the tests, the operation can be postponed. The operation is performed strictly on an empty stomach; the patient cannot even drink water. After the examination, the patient is escorted to the operating room, where he is placed on the operating table and put on a breathing mask. A mixture of oxygen and anesthesia medication is supplied to it, sleep occurs within a few minutes, and the operation ends for the patient - awakening occurs in the ward.

Doctors anesthesiologists

The clinic employs highly qualified anesthesiologists, including specialists from the Children's Clinical Hospital named after. N.F. Filatov, who have academic degrees of candidates and doctors of medical sciences, many years of unique work experience. Our specialists use an anesthetic apparatus from the German company Drager and the latest generation of medicines. All this allows operations to be performed under general anesthesia (anesthesia), which is safe for the patient’s health, with further rapid recovery in the postoperative period.

Drugs

In their work, anesthesiologists use the drugs sevoran, diprivan, esmeron, enfluron, isoflurane, dormicum and others. The choice of a specific drug is at the discretion of the anesthesiologist and depends on each specific case, test results and other factors.

Carrying out FGDS

The FGDS procedure lasts no more than ten minutes. If a biopsy is needed, it will take a little longer.

The patient is placed on his left side, after which the oral cavity and larynx are treated with a local anesthetic to reduce sensitivity.

A mouthpiece is placed in the mouth, through which the endoscopist inserts a tube with a probe. The doctor moves it deeper with gentle movements, examining the inner walls of the duodenum and stomach. If an ulcer or tumor is found, he will take a tissue sample for a biopsy. He will also remove detected polyps if necessary.

FGDS is a safe procedure, but in some cases it causes pain. Most often this occurs with ulcers or cancerous tumors. In these cases, the patient is recommended to undergo diagnostics under anesthesia.

Features of the postoperative period

The patient spends the postoperative period in our clinic in a comfortable room under the close supervision of the doctor on duty and nursing staff. On the day of surgery, the patient is allowed to drink water in small sips two hours after surgical treatment. Food is allowed to be consumed only the next day after surgery. The patient is fed in the clinic with pureed, soft foods; soda, sour juices, and spicy foods are excluded. The menu is selected by the clinic’s doctors and nutritionists personally for the patient.

Inpatient treatment after tonsillectomy in our clinic ranges from two to five days, depending on the general condition of the patient and the presence of concomitant pathology.

The patient’s task after the operation is to strictly follow the doctors’ recommendations (a gentle diet for 2 weeks, exclusion of physical activity and refusal to visit baths, saunas, swimming pools for 1 month), which will avoid complications such as bleeding, and also achieve a reduction terms of postoperative wound healing.

Relief of pain symptoms in children after tonsillotomy

One of the most common diseases of the ENT organs in childhood, diagnosed according to some data in more than 50% of preschool children [1], is hypertrophy of the palatine tonsils. The high prevalence of this condition in children is associated with a high frequency of surgical interventions on the tonsils, in our country this is mainly tonsillotomy. In Russia, tonsillotomy accounts for 25–30% of planned surgical interventions in a children's hospital [2]. According to foreign authors, the share of tonsillotomy (adenotonsillotomy) in those countries where this intervention is practiced in the structure of surgical interventions in otorhinolaryngological departments is more than 55% (for the age group of patients from 1 to 3 years). The main indication for tonsillotomy is obstructive sleep apnea syndrome [3].

Among the most common complications in the early postoperative period during tonsillotomy and other surgical interventions on the tonsils are bleeding and severe pain, which should not be underestimated in pediatric practice. Thus, according to recent studies, complications in the early postoperative period in patients after surgical interventions on the organs of the lymphopharyngeal ring in 48.1% were severe sore throat, and bleeding was noted only in 3.9% of cases. In 29.0% of patients, severe sore throat was the cause of severe dysphagia, and in 4.6% it was clinically manifested by dehydration [4]. In children under 6 years of age, pain in the throat in the early postoperative period is mainly accompanied by nausea and vomiting [5].

Thus, one of the pressing problems of all modern clinical medicine and otorhinolaryngology in particular is postoperative pain relief. When analyzing previously published materials, one cannot fail to note the particularly great importance of non-steroidal anti-inflammatory drugs in minimizing pain after surgery on the tonsils [6].

The drug lysine salt of ketoprofen, which has anti-inflammatory, analgesic and antipyretic properties, with a rapid onset and duration of action of up to 8 hours, combined with very good tolerability, is of certain interest in terms of pain relief [7]. According to comparative randomized clinical studies of ketoprofen, lysine salt in a dose of 50–100 mg has a stronger analgesic effect than paracetamol/codeine combinations [8].

Taking into account the above problem, a clinical study was conducted at the clinical sites of the Department of Pediatric Otorhinolaryngology of the Federal State Educational Institution of Further Professional Education of the Russian Medical Academy of Postgraduate Education, the purpose of which was to increase the effectiveness of pain relief after tonsillotomy in children.

The study included 140 children aged 6 to 18 years (mean age 9.49 years) after radiowave tonsillotomy under endotracheal anesthesia. As a premedication before surgery, patients received only atropine solution (sublingually). In all patients, tonsillotomy (in 121 patients in combination with adenotomy using the Kozlov-Karpov method) was performed using a radio wave surgery device. A direct incision through the tissue of the palatine tonsil was made using a monopolar needle electrode in the “cut and coagulation” mode. Non-steroidal anti-inflammatory drugs were prescribed to relieve pain in the early postoperative period. All children, according to the sequential number randomization method, were divided into four groups.

Patients of the 1st group (35 people) received the drug ketoprofen lysine salt in the form of an oral solution (OKI drug, produced by Dompe, Italy) 40 mg (children aged 6 to 14 years) or 80 mg (children over 14 years old) and older) if there are complaints of severe, unbearable sore throat with an interval between doses of the drug of at least 8 hours.

Patients of the 2nd group (35 people) received the drug ketoprofen lysine salt in the form of an oral solution (OKI drug, produced by Dompe, Italy) 40 mg (children aged 6 to 14 years) or 80 mg (children from 14 years old and older) 3 times a day (at least 8 hours between doses) for 3 days after surgery.

Patients of the 3rd group (35 people) received ibuprofen orally (Nurofen, syrup 100 mg/5 ml, manufactured by Reckitt Benckiser Healthcare International Ltd., UK) 100-300 mg (child weight 17-20 kg - 150 mg each ; child weight 21-30 kg - 200 mg; child weight 31-40 kg - 300 mg) up to 3 times a day if there are complaints of severe, unbearable sore throat.

Patients of the 4th group (35 people) received the drug ketoprofen lysine salt in the form of a solution for topical use (OKI drug, produced by Dompe, Italy) 4 ml (children aged 6 to 12 years) or 6 ml (children over 12 years old) and older) 2 times a day (morning and evening) for 3 days after surgery. A single dose of rinsing solution was diluted in 100 ml of drinking water immediately before use. The patient performed the first gargling with this solution 3 hours after surgery, regardless of the severity of the pain syndrome.

Control examinations of patients were carried out 3, 6 hours after surgery, on the 1st, 2nd and 3rd days after surgery.

The study did not include children with diseases and conditions that are a contraindication for the prescription of the drug ketoprofen lysine salt in the form of granules for the preparation of an oral solution (for patients of the main groups) and ibuprofen (for patients of the control group), as well as patients with concomitant diseases, changing, in the opinion of the researcher, the natural course of the disease, affecting the result of therapy and/or violating the possibility of subjective assessment of the symptoms of the disease (psychoneurological pathology, diabetes mellitus, blood diseases, oncological diseases, immunodeficiency states, infectious diseases, etc.).

The evaluation of the effectiveness of treatment was carried out by the curator personally, noting the patient’s condition at the agreed time, entering into the primary documentation (inpatient card) the frequency of vomiting, the presence of nausea and the presence of bleeding from the surgical field. If bleeding occurred in the early postoperative period, the doctor carried out a set of measures to achieve stable hemostasis. If a patient vomits more than 2 times and severe nausea, the patient was given a single intravenous injection of metoclopramide solution (based on the patient’s body weight); if vomiting occurs more than 3 times, infusion therapy with glucose-saline solutions was performed.

Starting from the first day after surgical treatment (3 hours after surgery), the patient independently subjectively assessed the severity of pain in the throat and nausea on the basis of a 10-point visual analogue scale, where “0” points were the absence of a symptom, “10” points - maximum severity of the symptom. Patients of the 1st and 2nd groups, when taking the drug ketoprofen lysine salt in the form of an oral solution for the first and second time, assessed the ability to swallow the medicine (they could or not) and the organoleptic properties of the drug (whether they liked the taste or not). Patients of the 4th group, during the first and second gargling with a solution of ketoprofen lysine salt, assessed the possibility of using this form of medication and the organoleptic properties of the drug (whether they liked the taste or not).

The assessment of the safety of therapy was carried out by assessing the patient’s condition in a timely manner, noting in the primary documentation (inpatient card) the corresponding changes in the patient’s condition (the appearance of pathological elements on the skin, diarrhea, nausea, shortness of breath, etc.). On the 2nd day after surgery, all patients underwent capillary blood sampling for a general clinical blood test.

Statistical processing of the results was carried out using the Statistica v.6.0 program. To compare quantitative characteristics, Student's t-test was used, and to compare qualitative characteristics, Pearson's c2 test was used. The difference was considered statistically significant at p < 0.05.

Results and discussion

According to the visual analogue scale (VAS), at the first examination after surgery, patients of all groups had the same severity of sore throat (p > 0.05). This indicator was 6.4 ± 0.3 points in patients of the 1st group, 6.8 ± 0.5 points in the 2nd group, 6.2 ± 0.4 points in the 3rd group, 4th groups - 6.5 ± 0.5 points. Nausea and vomiting were noted in the 1st group in 7 (20%) people, in the 2nd group - in 8 (22.9%), in the 3rd - in 6 (17.1%) and in the 4th group - in 8 (22.9%) people. There was no bleeding in any patient. In the 1st group, 17 (48.6%) patients asked for an anesthetic drug, in the 3rd group - 14 (40%) patients.

During the control examination 6 hours after surgery, the severity of sore throat was 4.2 ± 1.2 points in patients of the 1st group, 1.6 ± 0.8 points in the 2nd group, 1.6 ± 0.8 points in the 3rd group - 4.8 ± 1.4 points, in group 4 - 3.4 ± 1.2 points. There was no statistically significant difference in indicators (p > 0.05). At the second examination (6 hours after surgery), 9 patients of the 1st group and 13 patients of the 3rd group asked for an anesthetic drug. However, none of the patients in groups 2 and 4 asked the doctor for an anesthetic during the follow-up examination.

During a control examination 6 hours after surgery, complaints of nausea and vomiting were reported by 9 (25.7%) patients of group 1 (all did not receive painkillers after the first examination), 1 (2.9%) patient of group 2, 11 (31.4%) patients (8 of them did not receive pain medication at the initial examination) of the 3rd group and 4 (11.4%) patients of the 4th group. 2 out of 3 patients of the 3rd group, who continued to have nausea after taking ibuprofen syrup, noted that a feeling of nausea arose after taking the drug. None of the patients had bleeding.

When examining patients 24 hours after surgery, according to VAS data, the severity of sore throat in patients of the 1st group was 3.5 ± 0.8 points, in the 2nd group - 1.2 ± 0.4 points, in 3 in group 4.5 ± 0.8 points, in group 4 — 3.2 ± 0.6 points. The severity of pain in patients of group 2 was significantly less than in patients of groups 1, 3 and 4 (p < 0.05). The difference between VAS scores for the severity of sore throat between patients of groups 1, 3 and 4 was not statistically significant (p > 0.05). One day after the operation, 1 (2.9%) child from the 1st observation group and 2 (5.7%) patients from the 3rd group complained of nausea. None of the patients had bleeding.

When examining patients 48 hours after surgery, according to VAS data, the severity of sore throat in patients of group 1 was 2.7 ± 0.6 points, in group 2 - 0.8 ± 0.2 points, in group 3 in group 3.6 ± 0.5 points, in group 4 — 2.5 ± 0.6 points. The severity of pain in patients of group 2, as at the previous examination, was significantly less than in patients of groups 1, 3 and 4 (p < 0.05). The difference between VAS scores for the severity of sore throat between patients of groups 1, 3 and 4 was not statistically significant (p > 0.05). No child complained of nausea. None of the patients had bleeding. According to the results of a clinical blood test taken on the second day after surgery, no pathological changes were detected in any patient under our supervision.

When examining patients 72 hours after surgery, according to VAS data, the severity of sore throat in patients of group 1 was 1.4 ± 0.5 points, in group 2 - 0.4 ± 0.05 points, in group 3 in group 1.8 ± 0.5 points, in group 4 — 1.4 ± 0.4 points. The severity of pain in patients of group 2, as at the previous examination, was significantly less than that in patients of groups 1, 3 and 4 (p < 0.05). The difference between VAS scores for the severity of sore throat between patients of the 1st, 3rd and 4th groups is not statistically significant (p > 0.05). No child complained of nausea. None of the patients had signs of bleeding.

According to the results of a follow-up examination of patients 10 days after surgery, not a single patient had complaints of bleeding from the oropharynx. None of the patients complained of discomfort in the throat. A retrospective assessment by patients (or their official representatives) of the ease of use of the drug ketoprofen lysine salt in the form of granules for the preparation of an oral solution (patients of the 1st and 2nd groups) showed that all patients noted the ease of use of this dosage form and only 3 ( 8.6%) patient of the 1st group and 1 (2.9%) patient of the 2nd group described the taste of the drug as “unpleasant”. However, this did not affect the possibility of further use of the drug. A similar survey of patients of the 4th group who used gargling with a solution of ketoprofen lysine salt for pain relief showed that 28 patients (80%) found this form of use convenient, while the remaining 7 patients were also able to use this form of the drug as prescribed by the doctor. Moreover, all 7 patients who noted some inconvenience in using this form of the drug were under the age of 10 years. The organoleptic properties of the rinse solution were rated as “pleasant” by 30 (85.7%) patients.

conclusions

Based on the above, we can conclude that in patients who have undergone radio wave tonsillotomy, a course of ketoprofen lysine salt solution for oral administration in the early postoperative period has an advantage over a single use (in the presence of severe sore throat) of this form of the drug or ibuprofen syrup according to effectiveness in relieving pain in the throat. A course of oral administration of a solution of ketoprofen lysine salt can reduce the frequency of complaints of nausea on the first day of surgery.

The form of the drug solution of ketoprofen lysine salt for gargling with a course of use in the early postoperative period in this category of patients gives an effect in reducing sore throat, comparable to a single oral administration of painkillers used during observation, but is inferior to the analgesic effect of a course of use of a ketoprofen solution lysine salt for oral administration. Also, this form of the drug is not always convenient for use in children under 10 years of age.

None of the patients under observation showed signs of serious adverse drug reactions from the use of the above-mentioned drugs, requiring the patient to be excluded from the study and provided with appropriate medical care. Complaints of a number of patients about nausea and vomiting are probably related to the anesthesia treatment the child underwent, since they were noted in patients of the 1st and 3rd groups, regardless of the fact that an anesthetic was used. However, in some cases, nausea cannot be ruled out as a consequence of taking an anesthetic drug.

The results of our observation in comparison with the available literature data allow us to conclude that a course of use in the early postoperative period of a solution of ketoprofen lysine salt for oral administration in patients who have undergone radio wave tonsillotomy has an advantage over a one-time use (due to severe sore throat) of a similar drug, ibuprofen syrup and ketoprofen lysine salt solution for gargling. At the same time, the subjectivity of a number of criteria for assessing the effectiveness of these drugs determines the relevance of further study of the issue of the peculiarities of the use of non-steroidal anti-inflammatory drugs in the early postoperative period in children after surgical interventions on the organs of the lymphopharyngeal ring.

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E. P. Karpova, Doctor of Medical Sciences, Professor D. A. Tulupov1, Candidate of Medical Sciences V. A. Grabovskaya F. A. Fedotov

Federal State Budgetary Educational Institution of Further Professional Education RMANPO Ministry of Health of the Russian Federation, Moscow

1 Contact information

Relief of pain symptoms in children after tonsillotomy / E. P. Karpova, D. A. Tulupov, V. A. Grabovskaya, F. A. Fedotov

For citation: Attending physician No. 1/2018; Page numbers in the issue: 22-25

Tags: children, tonsils, postoperative period